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Arthroscopic reduction of intra articular distal radius

fractures and treatment of ligament lesions


Practical explanations, tips and tricks

JM Cognet
SOS Mains Champagne Ardenne
Polyclinique Saint Andr, 5 Boulevard de la paix
51100 REIMS, France http://www.mainetpoignet.com

Interest of wrist arthroscopy for the treatment of

intra articular fracture of the distal radius has been


demonstrated in the literature.

Lindau T, Arner M, Hagberg L : Intraarticular lesions in distal fractures of the radius in young adults a descriptive arthroscopic study in 50 patients.
J Hand Surg (Br), 1997, 22, 638-643

Freeland AE, Geissler WB The arthroscopic management of intra-articular distal radius fractures. Hand Surg. 2000, 5(2), 93-102.

Ruch DS, Vallee J, Poehling GG, Paterson Smith B, Kuzma GR. Arthroscopic reduction versus fluoroscopic reduction in the management of intraarticular distal radius fracture. J arthroscopic related surgery, 2004, 3, 225-230

Edwards CC, Haraszti CJ, McGillivary GR, Gutow AP. Intra-articular distal radius fractures : arthroscopic assessment of radiographically assisted
reduction. J Hand Surg [Am], 2001, 26(6), 1036-1041

Adolfsson L, Jrgsholm P. arthroscopically-assisted reduction of intra-articular fractures of the distal radius. J Hand Surg [Br], 1998, 23(3), 391-395

Mathoulin C, Sbihi A, Panciera P. intrt de larthroscopie du poignet dans le traitement des fractures articulaires du infrieur du radius :
propos de 27 cas. Chir Main. 2001, 20(5), 342-50

Cognet JM, Bonnomet F, Ehlinger M, Dujardin C, Kempf JF, Simon P. Contrle arthroscopique dans le traitement des fractures articulaires du
radius distal : propos de 16 cas. Rev chir Orthop. 2003, 89, 515-523

Hattori Y, Doi K, Estrella EP, Chen G. Arthroscopically assisted reduction with volar plating or external fixation for displaced intra-articular
fractures of the distal radius in the elderly patients. Hand Surg. 2007;12(1):1-12

del Pial F. Dry arthroscopy of the wrist : its role in the management of articular distal radius fracture. Scand J Surg. 2008;97(4):298-304

Cognet JM, Martinache X, Mathoulin C. Arthroscopic management of intra-articular fractures of the distal radius. Chir Main. 2008 Sep;27(4):171-9

Interest of arthroscopic control


Analysis of the fracture
Help for reduction

Diagnosis of associated lesions

Analysis of the fracture

Articular surface of the radius is not flat but concave

Which exam would be the best to


evaluate the fracture ?

X-Ray ?
TDM ?
Fluoroscopy ?

Using standard
X-Ray, what
can we see ?

Front view

Lateral view

In fact, the fracture and its reduction were


poorly evaluated
Arthroscopic control would have shown this
displacement of the ulnar side of the radius

TDM ?

Analysis of the fracture


Auge W, Velasquez P. The application of Indirect reduction techniques in the distal
radius : the role of adjuvant arthroscopy. Arthroscopy, 2000, 16, 830-835

After arthroscopic control, an additional step has been necessary


in 70% of the patients

Arthroscopic control is the only way to asses the quality

of your reduction
Fluoroscopy alone cant show the state of the reduction

But dont forget that arthroscopic control is


only one part of your treatment which is
composed of three stages
First stage : reduction and stabilisation of the fracture

Second stage : arthroscopic control


Analysis of the fracture
Help for reduction
Treatment of associated lesions

Third stage : stabilisation of epiphiseal part of the

radius

First stage : reduction and stabilisation of the fracture

Traction of the wrist is not necessary

most of the time we use an anterior locking plate, with anterior approach

K-wires or spatula can help for the reduction of the fracture

Reduction is evaluated using fluoroscopic control

Second stage : arthroscopic control

Second stage : arthroscopic control

Plate is fixed on the anterior side of the wrist using a non locking screw

Partial synthesis of the distal part of the radius is done using one or two locking
screws
Evacuation of hemarthrosis is the first thing to do to evaluate the reduction of the
fracture

A needle is introduced in the radio-carpal articulation : this needle gives you information about
the direction of the K-wire you need to fix the fracture
The impacted part of the articular surface is reduced using the hook or a K-wire (used as a
joystick)
Once the reduction has been achieved, push the K-wire (with a motor) to fix it
Last step is the osteosynthesis of the distal part of the radius with locking screws

Articular fracture of the distal radius operated


with an anterior locking plate;reduction seems
to be good

2 K-wires were used to fix the


reduction of the fracture

K-wires need to be placed near


the subchondral surface and
sometimes between the locking
screws and the bone

K-wires were removed 6 weeks


after the operation

Young man, 22 years old, manual


worker
Articular fracture of the distal radius

b
c

b
c

c
a

d
d

b
a
a

b
c c

b
c
a

Arthroscopic control enabled :


- anatomic reduction of a complex intra-articular fracture of the distal
radius
- diagnosis and treatment of an acute scapholunate injury

Is arthroscopic reduction always possible ?


In my experience, you musnt take more than 90 mn to

operate a wrist fracture


Oedema
Skin complication
Difficult rehabilitation
Pain and stiffness +++

90 mn = 30 mn X 3
First 30 mn : osteosynthesis and partial reduction
Second 30 mn : arthroscopic control and articular reduction
Third 30 mn : last screws and treatment of associated lesions

Is arthroscopic reduction always possible ?


Your patient is more important than your arthroscopic

ability to operate on him


Arthroscopic control can show
Impossibility of reduction or reconstruction
Reduction possible but too difficult or too many injuries to treat

After one hour of operation, if you haven't obtained

reduction, remember you just have 30 mn to finish

First Step

Second Step

Locking plate and anterior


approach

Arthroscopic control

Reduction of the fracture


under arthroscopic control
and treatment of ligamentous
injuries

Third Step

Locking screws under the


articular surface

Reduction under arthroscopic


control is not possible

Open surgery or do nothing

Arthroscopic Assessment of Intra-Articular Distal Radius Fractures After Open Reduction and Internal Fixation From a Volar Approach
Kevin Lutsky, Martin I. Boyer, Jennifer A. Steffen, Charles A. Goldfarb Journal of Hand Surgery April 2008 (Vol. 33, Issue 4, Pages 476-484)

Associated injuries
Between 30 and 80%
Cartilaginous lesions (radius, capitatum)
Ligamentous injuries (scapho-lunate, luno-triquetral,

TFCC)

Are sometimes more important than the


fracture itself
Interest of arthroscopic control +++

Fresh injuries of scapho-lunate ligament


Geissler I

orthopaedic treatment
shrinkage

Fresh injuries of scapho-lunate ligament


Geissler I

Geissler II and III

orthopaedic treatment
shrinkage

shaving of scapho-lunate ligament


rduction
capsulodesis or scapholunate and scaphocapitate pinning for 6 to 8 weeks plus cast

Fresh injuries of scapho-lunate ligament


Geissler I

Geissler II and III

Geissler IV

orthopaedic treatment
shrinkage

shaving of scapho-lunate ligament


rduction
capsulodesis or scapholunate and scaphocapitate pinning for 6 to 8 weeks plus cast

open surgery or nothing


(is it really a fresh injurie ?)

Conclusion
Arthroscopy should be a routine procedure for the
treatment of an intra-articular fracture of the distal radius

- for a full diagnosis of all injuries


- for a better reduction of the fracture
- for early treatment of ligamentous injuries

Thank you for your attention